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Applications Will Be Pr*d When Submitte L.ICATIOi'J Completed. Be Su1* Sign The Application. <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED,GIVE <br /> ENGINEER'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> APPLICANT'S AND/OR PUBLIC POOLS.WATER SAMPLING <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS Li C. N0. <br /> BROKER ANO/OR POULTRY RANCHES AND KENNELS RegiSt. NO. <br /> 'InENSE AND/OR MISCELLANEOUS SERVICES <br /> STRATTON QOOr <br /> I, AER <br /> (Application Date Business/Name To Appear On Permit <br /> F <br /> Type Permit/Service Requested: Address P RO 508 ctk I <br /> — <br /> `ApplicantName C r to Service Cta+inn Fnu�a,T!?.� <br /> v Business Telephone No. Emergency Telephone No. <br /> J <br /> `Property Location/Address <br /> Address <br /> Property Owner Address <br /> -Operator's Name Restaurant, Maximum Seating Capacity <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage 13 MEAT MARKET <br /> 11 RESTAURANT 11 FOOD MARKET RETAIL 13 FOOD MARKET WHOLESALE <br /> ❑ COMMISSARY ❑ ICE PLANT 11BAKERY <br /> 11 FOOD PROCESSING PLANT ❑ 11 ITINERANT RESTAURANT <br /> 11 ROADSIDE FOOD STAND ❑ BAR LIQUOR STORE 11 FOOD VENDOR <br /> ❑ CONFECTIONARY STORE 11 FOOD SALVAGER ❑ FOOD DEMONSTRATION <br /> ❑ VENDING MACHINES/No. of <br /> ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No. of Units <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> CAL <br /> 3. WATER QUALITY 11 WATER SAMPLE (Bacterial) 11CH❑ (WATER HAULER <br /> ❑ PUBLIC WATER SYSTEM 11SURFACE WATER SUPPLY <br /> NO, OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEL/Runways /Animal Population No. No.of Confining Cages — <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Animal Waste Disposal Method <br /> Water Supply Source _. <br /> 6, V CONSULTATION FEE pi ing Samplinq Field Visit <br /> 7. ❑ .PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection[] Sample[] Title Company <br /> Sewage System Inspection <br /> ❑ Address Tele. No. <br /> Escrow No. <br /> Seller Seller Address <br /> Telephone No. . Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 A Receiv dBy July 31 <br /> REMBILLING REMITTANCE $ AMOUN UE ECKED <br /> BASE EXPLANATION DATE DATE REMITTED A OUNT_ <br /> FEE 35.00 1 18 89 <br /> LESS <br /> PRORATION <br /> PENALTY $ 3.50 Penalty 4/3/89 <br /> OTHER <br /> OTHER <br /> 4- CC, - ir 3 So <br /> Date Receipt No. Permit No. Issuance Date Mailed Deliveretl <br /> Received by 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 — <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />